Pediatric Payment Corner – August 2017

Beware: United Health Care is getting in the way of pediatric office billing.

Our office is in process of tracking an issue with United Health Care (UHC). We are currently working to find someone in charge of the MCOs to straighten out this issue.

In essence, sometimes a patient comes in and registers at our front desk as Medicaid, in this case specifically as United Health Care. Later we discover that they had private insurance. Blue Cross Blue Shield (BCBS) is a typical example. When we discover the discrepancy, we submit a claim to BCBS.

Our claim is then denied by BCBS as a duplicate because UHC/MDD is billing the primary themselves, instead of recouping the payment and telling us to bill the primary insurance. We always ask the patients for other coverage, but for some reason they don’t disclose it to us (ignorance? MDD fraud?).

When they find a primary, somehow, Medicaid Management Information System (MMIS) sends a claim to the commercial (primary) payer using HMS (a recovery audit contractor) and informs us of the primary. When we try to bill the primary, we are denied as a duplicate.

When we call commercial primary (here, BCBS), they tell us to give them a claim number, which we don’t have because we didn’t send a claim, UHC did.

We call UHC and ask them to withdraw their claim and recoup and they give us an explanation about “Post Pay Billing.”

We’ve had this happen once before and managed to get UHC to withdraw their claim, and now it is happening again.

The problem is, since

UHC pays claim at – $67.20

BCBS pays claim at ~ $126.00

We want to be paid by BCBS at $126.

Thus, UHC is paid $126 and we are paid $67.20, and they come out ahead.

What is supposed to happen (according to the TPL Manual) is HMS (or UHC?) is to “post pay bill” and recoup it from the provider

NOT send a claim to the primary, blocking our claim from going through (since it is considered a duplicate).

MMIS should NOT send claims to commercial insurance companies, pediatricians should. The TPL manager has to authorize this anyway – and basically, should not do that with a commercial insurance.

Alternatively, the TPL manager should direct HP staff(or UHC if that is how it is being handled) to withdraw their claim and let UHC recoup from the provider so that

we can get paid a commercial rate. (see Attached from “TPL Handbook, A Guide to Understanding Third Party Liability”), and

MDD/UHC is out nothing (since the primary paid us) or much less (since UHC would have much less to pay on a secondary claim).

None of the other Kansas MCOs (AMR, SUN) are doing this. Just UHC. So if it were a “federal mandate,” I’d think AMR and SUN would be doing it, too.

UHC should recoup and direct us to the primary, which they do on most of their discoveries of a primary and which is according to the protocol. However, when they do not follow protocol, they are apparently collecting what BCBS pays them and keeping the difference.

The current response from UHC is as follows.

“There is a federal mandate that requires us not to deny claims for primary coverage of certain services. i.e.; pediatrician preventative medicine

The mandate is called “Post Pay Billing.”

We (UHC) will always pay primary for these services

A biweekly file for those claims is then sent to our vendor who identifies claims that had primary coverage.

They (UHC) then bills the primary and

The primary processes and pays UHC.”

Under this system you (the pediatric office) will not see recoupments for these primary claims.

The only way to avoid this is to obtain primary information from the patient upfront and bill primary before UHC secondary. However, if the patient does not inform the front office because they do not understand or “forgot”, we have no way of knowing.